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MAOUND TANK DISPOSITION TRACKINGAOORD <br /> zxzxzxxxzxxzxxxxx:xxxxzxxxxxxxzxxxxxxzxxxxzxxzxxxxxxxzxxxxzxzxzxxxxxxxxx****x*****x*xxxxxzx <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification number. The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with nL]mfwr noted below is ream alhle for <br /> ensuring that this form is completed and jeturned, <br /> FACILITY NAME: <br /> FACILITY ADDRESS: ( 1 g/ Y- v,& S7l,-A-1 Cf S'2G3 <br /> TANK ID N39- /,2 <br /> zzxxxxxzxzxxzxzxxxxzxxxxxzxzxx**xx*x*xxxxxxxxxxzxxxxzxzxzzxzxxzzxzxxxxxxzxxxxxxxxzxxxxxxxxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank RemovalCConnttraacctor:_kl-� c•;,,i � e �; f?;z <br /> Address: �� "� - N r C'- Zip: <br /> PhoneN a3 - yy�-liz Y <br /> Telephone: pate Tank Removed: <br /> :zxxxxxxxxzxxzxzxzxxxxxxxxxxxxxzxzxxxxzzxxxzzxxx**x*zx**xx*z*x***xxzxxxxxxxx xzxx*xxxxzxzzz <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: 14e, /jrA <br /> Address: 2731' / F ��c ✓,�/a X11'1 ay <br /> Zip: <br /> -hone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated <br /> by Department of Health Services. <br /> �11 t' j. <br /> xxzzzxzxxxzxxxxzxxxxzxzzxzzxxzxzzxxxxxxSIGNATURE <br /> cxAND <br /> xzzTITLE <br /> xxzzzzxzzxxxzzxxzxzxxxxxzxzxxzxxxxxz <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name_ //Z /. ''�/C _ /� c c• Si¢c / t�si� ✓ 7G <br /> Address: Jf 7j l �� a �. Sifc l 3 <br /> /�-fiiN��T�' Zip: J�T� <br /> PhoneN: <br /> Date Tank Received: <br /> xxxxxxxxxzzzxzxzxzxxxxzxzxxxxxAUTHORIZED SIGNATURE AND*TITLE x****xx*x*****x**xzxzxxzxxzxx <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br /> T <br />